Based on a comparative study of cooperative work practices at two oncology clinics, the paper shows that work practices across these otherwise comparable settings vary significantly. Asking, how can ethnographic studies of local work practices then provide a dependable basis for design, the paper discusses how we may conceive of the relationship between ethnographic studies and systems development and suggests that a way out of the dilemma might be found in developing an analysis of the `higher-order' practices of endless combination and recombination of artifacts, formats, notations, etc. that are found across such sites. Categories and Subject Descriptors H.5.3 [Information Interfaces and Presentation]: Group and Organization Interfaces